Left Ventricular Thrombus Formation Research Articles

Direct Oral Anticoagulants versus Vitamin K Antagonists for the management of left ventricular thrombus after myocardial infarction: A meta-analysis

Abstract Background/Introduction Left ventricular (LV) thrombus formation is not an uncommon complication after acute myocardial infarction (AMI) in the modern era of early reperfusion. The optimal anticoagulation regimen in this clinical scenario remains poorly-defined. Purpose The present meta-analysis sought to investigate the efficacy and safety profile of direct oral anticoagulants (DOACs) compared with Vitamin K antagonists (VKAs) for the management of LV thrombus following AMI. Methods A systematic literature review was conducted in electronic databases to identify studies reporting efficacy and safety outcome data regarding the use of DOACs versus VKAs for patients with LV thrombus after MI. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated and random-effects meta-analyses were conducted to synthesize pooled ORs. Results Eight studies comprising a total of 605 patients were included (Table). DOACs were associated with an almost 2-fold higher likelihood for achieving thrombus resolution compared to VKAs (pooled OR 1.95 [1.25-3.04]; p =0.003, I2 =0 %), while they achieved a 70% lower risk for systemic embolism (pooled OR 0.30 [0.12-0.75]; p =0.01, I2 =0%). The use of DOACs was associated with a 54% lower risk for bleeding compared to VKAs (pooled OR 0.46 [0.26-0.84]; p =0.01, I2 =0 %). Overall, patients receiving DOACs had a 63% lower risk to reach the composite outcome of any bleeding, systemic embolism, cardiovascular hospitalization, or all-cause death, compared with patients using VKAs (pooled OR 0.37 [0.23-0.60]; p <0.0001, I2 =0%) (Figure). Conclusion DOACs appear to have a more favorable efficacy and safety profile compared to VKAs for the management of LV thrombus following AMI.Graphical abstractTable

The Role of Inflammation in Early Left Ventricular Thrombus Formation Following ST-Elevation Myocardial Infarction-A Matched Case-Control Study.

There is limited data on the association between inflammation and the formation of early left ventricular thrombus (LVT) following ST-elevation myocardial infarction (STEMI). This study aimed to explore the predictive value of several inflammatory biomarkers for LVT formation following STEMI. Our cohort included 2534 consecutive patients admitted to the cardiac intensive care unit (CICU) with STEMI. The final analysis included 51 patients with LVT and 102 patients without LVT, matched for age, sex, anterior infarct and ejection fraction. Upon admission, patients with LVT had higher white blood cell counts (WBC) (12.8 ± 7 vs. 12.4 ± 4 ×103/µL, p = 0.01), higher absolute neutrophil counts (10.5 ± 4 vs. 8.6 ± 4 ×103/µL, p = 0.003), neutrophil-to-lymphocyte ratio (8.2 ± 6 vs. 4.8 ± 4, p = 0.04), and C-reactive protein (CRP) levels (35.9 ± 62 vs. 18.6 ± 40 mg/L, p = 0.04). Peak values for WBC and CRP were also higher in the LVT group (17.8 ± 8 vs. 14.6 ± 5 ×103/µL, p = 0.003 and 95.8 ± 82 vs. 64.2 ± 76 mg/L, p = 0.02, respectively). In univariate regression analysis, WBC upon admission (OR: 1.12, 95% CI: 1.02-1.21, p = 0.02), peak WBC (OR: 1.09, 95% CI: 1.02-1.17, p = 0.009), neutrophil count upon admission (OR: 1.15, 95% CI: 1.04-1.26, p = 0.004), and peak CRP (OR: 1.01, 95% CI: 1-1.01, p = 0.03) predicted LVT formation, which was also evident in multivariate regression models. WBC and neutrophil counts upon admission, as well as peak WBC and CRP, have additional predictive value for LVT formation following STEMI, beyond classical risk factors.

Local experience of the use of type 2 sodium-glucose co-transporter inhibitors in patients with type 2 diabetes mellitus and acute coronary syndrome

Objective: to evaluate the course and outcomes of ACS in patients with type 2 diabetes taking SGLT-2 inhibitors. Materials and methods: the study included patients admitted to the Research Institute – Regional Clinical Hospital No. 1 n.a. Prof. S.V. Ochapovsky” Krasnodar from 01.11.2023 to 01.02.2024. Results: a retrospective analysis of medical documentation revealed that the number of patients with ACS while taking NGLT-2 inhibitors was significantly lower compared to those taking other glucose-lowering therapy. Patients taking iNGLT-2 had a significantly lower body mass index. Significant differences concern markers of liver dysfunction and microalbuminuria, which were significantly lower in the group receiving NGLT-2. In addition, these patients were less likely to experience hospital complications such as acute kidney injury, cardiac arrhythmias, ischemic stroke, left ventricular thrombus formation, and death. Conclusions: the results of local experience with the use of iNGLT-2 in hospitalized patients with type 2 diabetes and ACS are presented, confirming the metabolic and cardiorenal benefits of this class of drugs in real clinical practice. In addition, the study results clearly demonstrate a more stable course of ACS and a lower risk of in-hospital complications and mortality. However, these parameters did not achieve statistically significant results due to the small sample.

Direct Oral Anticoagulants Versus Vitamin K Antagonists for the Management of Left Ventricular Thrombus After Myocardial Infarction: A Meta-Analysis

Left ventricular (LV) thrombus formation remains a post-acute myocardial infarction (AMI) complication even in the modern era of early reperfusion. The optimal anticoagulation regimen in this clinical scenario is poorly defined. The present meta-analysis sought to investigate the efficacy and safety profile of direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs) for the management of LV thrombus after AMI. A systematic literature review was conducted in electronic databases to identify studies reporting efficacy and safety outcome data regarding the use of DOACs versus VKAs for patients with LV thrombus after AMI. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated, and random-effects meta-analyses were conducted to synthesize pooled ORs. Eight studies comprising a total of 605 patients were included. DOACs were associated with an almost twofold higher likelihood of thrombus resolution compared with VKAs (pooled OR 1.95 [1.25 to 3.04], p = 0.003, I2 = 0%), and decreased the risk of systemic embolism by 70% (pooled OR 0.30 [0.12 to 0.75]; p = 0.01, I2 = 0%). The use of DOACs was associated with a 54% lower risk of bleeding compared with VKAs (pooled OR 0.46 [0.26 to 0.84], p = 0.01, I2 = 0%). Overall, patients receiving DOACs had a 63% lower risk of reaching the composite outcome of safety and efficacy compared with patients using VKAs (pooled OR 0.37 [0.23 to 0.60], p <0.0001, I2 = 0%). In conclusion, DOACs appear to have a more favorable efficacy and safety profile compared with VKAs for the management of LV thrombus related to AMI.

Incidence of left ventricle thrombus formation in patients with STEMI in the current era of antithrombotic treatment

Abstract Funding Acknowledgements None. Introduction Left ventricular (LV) thrombus formation is a serious complication of acute ST-segment elevation myocardial infarction (STEMI) which may result in ischemic stroke and systemic thromboembolism. There is limited evidence on the incidence and impact of LV thrombus in STEMI patients in the current era of antithrombotic treatment. Purpose To evaluate the incidence of LV thrombus formation in STEMI patients and to assess clinical predictor factors of LV thrombus formation leading to in-hospital major cardiac events (MACCE). Methods We prospective collected data from 504 STEMI patients treated with primary percutaneous intervention (PCI) in our large volume university hospital from April 2019 to September 2019. All patients underwent echocardiography examination at presentation and at hospital discharge. Results Mean age of the patients was 66.2 years and 78.8% were male. The incidence of LV thrombus formation was 5% in overall cohort and 9.4% in anterior STEMI. Among patients with LV thrombus, the majority had anterior STEMI (96% vs 48.4%; p&amp;lt;0.001), lower LV ejection fraction (LVEF)(35% vs 43%; P&amp;lt;0.001), more increased LV dimension /volume (36%vs7.3%; p&amp;lt;0.001), more apical aneurism/dyskinesia presence (36% vs 9%; p&amp;lt;0.001), longer ischemia time (25 hours vs 14 hours; p&amp;lt;0.002), more increased TPI values (p-0.22) and underwent less coronary angiography (p&amp;lt;0.02) and primary PCI (P=0.021). Increased LV dimension/volume was associated with 3.35 times higher risk of having LV thrombus (p=0.023). Also anterior STEMI was associated with 14 times higher risk of having LV thrombus=0.012. Patients with LV thrombus had a numerically higher incidence of in-hospital MACCE events (20% vs 13.5%; p=0.36). Conclusion The incidence of LV thrombus formation in STEMI still remain high regardless of primary PCI treatment and current antithrombotic treatment, and is higher in patients with anterior STEMI, lower LVEF, adverse ventricular remodeling, apical aneurism/dyskinesia presence, late hospital presentation and longer ischemia time. The presence of LV thrombus was independently associated with in-hospital MACCE events.

Left ventricular reverse remodelling as a promising strategy for resolving left ventricular thrombus.

Recent years, several studies have suggested that abnormal baseline left ventricular (LV) function and structure are associated with left ventricular thrombus (LVT) formation. Despite this, most studies have given less attention to the potential role of left ventricular reverse remodelling (LVRR), that is, the improvement of LV function and structure, in resolving LVT. In this study, we aim to investigate the clinical characteristics, prognosis, and LVT resolution in patients with LVRR. This is a retrospective study conducted at The First Affiliated Hospital of Dalian Medical University. Our cohort consists of patients diagnosed with LVT between 1 November 2015 and 31 May 2020. Enrolled patients were categorized into two groups: LVRR and Failure of LVRR. The primary endpoints included LVT resolution and embolic events. A total of 84 patients were included in the study, with 59 patients in the LVRR group and 25 patients in the Failure of LVRR group. In our study, patients in the LVRR group experienced higher incidence of LVT resolution and a lower risk of embolic events. Multivariate logistic analysis revealed that Failure of LVRR was the only independent negative predictor for LVT resolution and positive predictor for embolic events. Patients with LVRR experience higher incidence of LVT resolution and have lower risk of embolic events, highlighting the significance of identifying and mitigating risk factors that contribute to abnormal LV function and structure in management of patients with LVT.

Elevated factor XI is associated with recurrent left ventricular thrombus of unknown origin.

Elevated factor XI (FXI) has been shown to predispose to thromboembolism. We investigated whether it is associated with left ventricular thrombus (LVT) formation, its recurrence and subsequent thromboembolic events. In 54 patients with prior LVT of unknown origin, who stopped anticoagulation and 54 controls, we determined FXI, along with plasma clot permeability (Ks), fibrinolysis time (CLT), endogenous thrombin potential (ETP), von Willebrand factor (vWF) and fibrinolysis proteins. During follow-up, the primary endpoint involving the recurrence of LVT a symptomatic ischemic stroke or systemic embolism was recorded. Elevated (>120%) FXI levels were more often observed in LVT patients when compared to the control group (14 [25.9%] vs. 6 [11.1%], p = .048) in association with the presence of active FXI. FXI correlated with age (r = .406, p = .002), Ks (r = -.542, p < .001) and CLT (r = .406, p = .002), also after adjustment for age, but not with ETP, vWF or fibrinolysis proteins. During follow-up of 77.6 ± 18.5 months the primary endpoint occurred in 17 (31.5%) LVT patients, including 11 (20.4%) recurrent LVT, and in 4 (7.4%) controls (annual incidence rate 4.9% vs. 1.1%, respectively; p = .002). On multivariate logistic regression analysis, elevated FXI was independently associated with the primary endpoint (OR 1.18; 95% CI 1.09-1.28). Elevated FXI in association with a prothrombotic state characterizes patients with prior LVT of unknown origin and predisposes to its recurrence and/or ischemic stroke during follow-up. It might be speculated that the measurement of FXI helps identify patients who could benefit from prolonged anticoagulation and FXI inhibitors in the future.

Prophylactic Anticoagulation to Prevent Left Ventricular Thrombus Following Acute Myocardial Infarction: A Systematic Review and Meta-Analysis

Clinical practice guidelines from the American Heart Association recommend consideration of prophylactic anticoagulation to prevent left ventricular thrombus (LVT) formation in anterior ST-elevation myocardial infarction (STEMI) patients. These guidelines were given a low certainty of evidence (Class IIb, Level C), relying primarily on case studies and expert consensus to inform practice. Our objective was to compare the safety and efficacy of prophylactic anticoagulation, in addition to dual antiplatelet therapy (DAPT), in the current era of timely primary percutaneous coronary intervention (pPCI). EMBASE, MEDLINE and Cochrane Library were systematically searched from January 2012 through June 2022. A total of 7,378 publications were screened, and 5 publications were eventually included in this review: 1 randomized control trial and 4 retrospective studies involving 1,461 patients. Data were pooled using a fixed effects model and reported as odds ratios (OR) with 95% confidence intervals (CI). The primary outcome of interest was the rate of LVT formation, and the secondary outcomes were the rate of major bleeding and systemic embolism. Pooled analysis showed a significantly lower rate of LVT formation (OR: 0.28 [95% CI: 0.11–0.73; p < 0.01]) and significantly higher rates of bleeding (OR: 2.85 [95% CI: 1.13–7.24; p= 0.03]) in the triple therapy (TT) group compared to DAPT. No significant difference was observed in the rate of systemic embolism between the groups (OR: 0.37 [95% CI: 0.12–1.13; p = 0.08]). In this meta-analysis, there is no conclusive evidence to either support or oppose the use of TT for LVT prevention in anterior STEMI patients treated with pPCI. Appropriately powered randomized controlled trials are warranted to further evaluate the benefits of LVT prevention against the risks of major bleeding in this population.

Clinical predictors of left ventricular thrombus after myocardial infarction as detected by magnetic resonance imaging.

The diagnosis of a left ventricular (LV) thrombus in patients with ST-segment elevation myocardial infarction (STEMI) remains challenging. The aim of the current study is to characterize clinical predictors for LV thrombus formation, as detected by cardiac magnetic resonance imaging (CMRI). We retrospectively evaluated 337 consecutive STEMI patients. All patients underwent transthoracic echocardiography (TTE) and CMRI during their index hospitalization. We developed a novel risk stratification model (ThrombScore) to identify patients at risk of developing an LV thrombus. CMRI revealed the presence of LV thrombus in 34 patients (10%), of whom 33 (97%) had experienced an anterior wall myocardial infarction (MI), and the majority (77%) had at least mildly reduced left ventricular ejection fraction (LVEF < 45%). The sensitivity for thrombus formation of the first and second TTE was 5.9% and 59%, respectively. Multivariate logistic regression model revealed that elevated C-reactive protein levels, lack of ST-segment elevation (STe) resolution, elevated creatine phosphokinase levels, and STe in anterior ECG leads are robust independent predictors for developing an LV thrombus. These variables were incorporated to construct the ThrombScore: a simple six-point risk model. The odds ratio for developing thrombus per one-point increase in the score was 3.2 (95% CI 2.1-5.01; p < 0.001). The discrimination analysis of the model revealed a c-statistic of 0.86 for thrombus development. The model identified three distinct categories (I, II, and III) with corresponding thrombus incidences of 0%, 1.6%, and 27.6%, respectively. ThrombScore is a simple and practical clinical model for risk stratification of thrombus formation in patients with STEMI.

Incidence and Predictors of Left Ventricular Thrombus Formation After Acute Myocardial Infarction With ST-Segment Elevation.

Background and objective Our prospective study aimed to evaluate the frequency and risk factors of left ventricular thrombus (LVT) occurring after acute ST-segment elevation myocardial infarction (STEMI) in the era of primary percutaneous coronary intervention (PCI). Methods Our study included 131 patients diagnosed with acute STEMI who were followed up and treated. The presence of the thrombus was determined by transthoracic echocardiography (TTE). Study patients were evaluated as cases of thrombus (+) and thrombus (-). The relationship of electrocardiographic measurements such as the number of leads with pathological Q waves, ST segment deviation score, QT dispersion, and echocardiographic measurements such as ejection fraction (EF), end-systolic and end-diastolic volumes, and wall motion score index (WMSI) with LVT was investigated. LVT risk factors were identified. Results The median age of the study patients was 59.7 ± 11.7 years, and 84.7% were male. The incidence of LVT was 17.6% (23 patients). While the anterior STEMI rate was 86.9% in the thrombus (+) group, it was 50.9% in the thrombus (-) group (p<0.001). While WMSI was 2.1 ± 0.44 in the thrombus (+) group, it was calculated as 1.40 ± 0.31 in the thrombus (-) group (p<0.001). In the thrombus (+) group, EF was found to be lower, end-systolic and end-diastolic volumes were higher, and the rate of moderate and severe mitral regurgitation and the rate of aneurysmatic segment detection were higher. LVT had a moderate correlation with WMSI (r: 0.613; p<0.001), the presence of an aneurysmatic segment (r: 0.549; p<0.001), and EF (r: -0.514; p<0.001). Presentation with anterior STEMI (odds ratio [OR]: 4.266; p<0.001), WMSI (OR: 7.971; p=0.012), the number of leads with pathological Q waves detected at discharge (OR: 3.651; p=0.009), the presence of an aneurysmatic segment (OR: 2.089, p=0.009), and EF (OR: 1.129, p=0.006) were identified as independent risk factors of the presence of LVT. The area under the curve for WMSI was found to be 0.910 (95% CI: 0.852-0.968). A WMSI cut-off of 1.56 identified LVT with 91% sensitivity and 70% specificity (Youden index: 0.617). Conclusion In the primary PCI era, LVT incidence after acute STEMI is still significant. Anterior STEMI, the number of leads with pathological Q waves detected at discharge, WMSI, aneurysm formation, and low EF are independent risk factors for LVT. Among these risk factors, the variable with the highest diagnostic power is WMSI.

Meta-analysis of cardiac imaging modalities for the diagnosis of left ventricular thrombus following acute myocardial infarction

Abstract Background The formation of left ventricular thrombus (LVT) in post-acute myocardial infarction (AMI) patient carries significant risk of systemic embolism. Hence, there is a need to adopt strategies aimed at accurate and early diagnosis of LVT in order to mitigate the risk of embolic events with anti-thrombotic therapy. We aimed to conduct a systematic review and meta-analysis to appraise the current literature on the various diagnostic modalities used in post-AMI LVT detection. Methods We conducted a comprehensive search in Medline, EMBASE, and Scopus using an appropriate keyword/MeSH term search strategy up to 31 December 2021. All studies reporting a comparison between at least two imaging modalities in the diagnosis of LVT in post-AMI patients were included. Results A total of 2039 patient from 11 studies published between 2006 and 2021 were studied. Across all study populations, a majority of patients were male (82.3%) and the overall incidence of LVT was 15.2%. Using delayed-enhancement cardiac magnetic resonance imaging (DE-CMR) as the gold standard reference, transthoracic echocardiogram (TTE) with ultrasound enhancing agent (UEA) had the highest sensitivity (0.886, 95% CI 0.667-0.967) and specificity (0.980, 95% CI 0.900-0.996), while cine-CMR had the best diagnostic performance in terms of positive likelihood ratio (LR+ 437, 95% CI 37.2-1890), negative likelihood ratio (LR- 0.246, 95% CI 0.118-0.423) and diagnostic odds ratio (DOR 2050, 95% CI 134-9590). The summary receiver operating characteristic curves (SROCs) of the three studied imaging modalities were plotted and the AUC values were 0.920, 0.974 and 0.989 for TTE without and with UEA, and cine-CMR. Conclusions The diagnostic modalities used for LVT detection examined in this study had good specificity but poor sensitivity when compared to DE-CMR. Post-AMI patients at higher risk of LVT formation may benefit from further imaging studies with DE-CMR if initial TTE were negative.

Clinical characteristics and outcomes of left ventricular thrombus patients with mildly reduced and preserved left ventricular ejection fraction

Abstract Background Abnormal left ventricular ejection fraction (LVEF) is associated with the development of left ventricular thrombus (LVT) following acute myocardial infarction and also in non-ischaemic cardiomyopathies. LVT formation in normal LVEF is less common. Purpose We aimed to describe the clinical characteristics and outcomes of patients with LVT and LVEF&amp;gt;40%, and compare them against patients with LVT associated with LVEF≤40%. Methods We retrospectively studied 551 consecutive patients with LVT from our tertiary centre’s echocardiography database between March 2011 and January 2021. We compared baseline co-morbidities and echocardiographic parameters between patients with LVT and LVEF&amp;gt;40% versus LVEF≤40%. The Kaplan Meier method with log-rank test was used to compare rates of thrombus resolution, stroke and all-cause mortality between the 2 groups. Multivariable Cox regression models were constructed to correct for potential confounders. Results Mean age of the study population was 59.8 ± 12.9 years old and 86/551 (15.6%) were female. LVT in patients with LVEF&amp;gt;40% made up 100/551 cases (18.1%), of which 91.0% were associated with ischaemic heart disease. Patients with LVEF&amp;gt;40% were younger and had fewer cardiovascular co-morbidities than their counterparts with LVEF≤40%, including a lower prevalence of hypertension, hyperlipidaemia, diabetes mellitus, ischaemic heart disease and heart failure (Figure 1). Patients with LVEF&amp;gt;40% more often had a smaller thrombus (mean diameter 14.1 ± 5.9 mm) compared to those with LVEF≤40% (mean diameter 17.2 ± 8.2 mm). LVT with LVEF&amp;gt;40% was independently associated with thrombus resolution (HR 1.42, 95% CI 1.08–1.87, p=0.013) corrected for anticoagulant use, as well as lower mortality (HR 0.49, 95% CI 0.26–0.94, p=0.031) corrected for baseline co-morbidities (Figure 2). LVEF did not influence stroke rates. Conclusions In patients with LVEF&amp;gt;40%, LVT was less common. These patients had fewer cardiovascular co-morbidities, developed smaller thrombi, were more likely to have thrombus resolution and had a lower mortality rate. However, overall stroke risk was similar to patients with a reduced LVEF.Figure 1:Baseline characteristicsFigure 2:Outcomes

Left ventricular thrombus in patients with heart failure with improved ejection fraction

Abstract Background This study sought to: (1) determine the prevalence of LV thrombus at baseline and at the time of recovered ejection fraction (EF) in patients with heart failure with improved ejection fraction (HF-imp EF), (2) examine clinical and echocardiographic factors associated with the presence of LV thrombus, and (3) determine the prevalence of thromboembolic events when LVEF was improved and oral anticoagulant (OAC) was discontinued. Methods and results Patients with nonischemic HF-imp EF defined as a baseline LVEF of ≤ 40%, a ≥ 10% increase from baseline LVEF, and a second measurement (6 months apart) of LVEF of &amp;gt; 40% were consecutively enrolled in advanced HF clinic in a tertiary center. Patients with recent myocarditis, recent coronary revascularization, active chemotherapy, hypertrophic cardiomyopathy, cardiac amyloidosis, and tachycardia induced cardiomyopathy were excluded. A total of 104 consecutive patients (age 51 ± 15 years; 66% were male) with HF-imp EF were included. Of these, 14 patients (14%) had LV thrombus at baseline. Baseline LVEDD, LVEF, and LV global longitudinal strain (GLS) were 61 ± 10 mm, 23 ± 15%, and -5.9 ± 3.3%, respectively. Younger age, absence of atrial fibrillation, receiving oral diuretics, lower LVEF, reduced LV GLS, and reduced RV free wall (FW) GLS were significantly associated with LV thrombus at baseline (p &amp;lt; 0.05 for all) (Table 1). All patients (100%) with LV thrombus at baseline received oral anticoagulants (OAC). At the median follow-up of 27 months, 14 (100%) had complete resolution of LV thrombus when LVEF &amp;gt; 40%. Of 14 patients, 11 (79%) who were in sinus rhythm discontinued OAC. After a median further follow-up of 27.4 months following OAC discontinuation, there was no thromboembolic event or all-cause mortality in these patients. One of 11 patients developed worsening LVEF and recurrent LV thrombus at 25 months after LVEF improvement (&amp;gt; 40%). Conclusions Approximately 1 in 6 patients with HF-imp EF had LV thrombus at baseline. LV thrombus formation was associated with more impaired LV and RV systolic function and myocardial deformation implicating more thromboembolic milieu. Complete resolution of LV thrombus occurred in all patients who were on OAC therapy at the time of imp-EF. Discontinuation of OAC when LVEF &amp;gt; 40% was safe. However, recurrent thrombus formation can occur when LV systolic function was deteriorated. Annual or bi-annual echocardiographic follow-up may be essential in these patients.

SYSTEMIC IMMUNE-INFLAMMATION INDEX IS A PREDICTOR OF LEFT VENTRICULAR THROMBUS FORMATION FOLLOWING ANTERIOR MYOCARDIAL INFARCTION

Introduction: Left ventricular thrombus (LVT) formation following anterior ST-elevation myocardial infarction (STEMI), is a serious complication and is associated with an increased risk of cardiovascular morbidity and mortality. Recently introduced the systemic immune-inflammation index (SII) is a reliable indicator of adverse events in various cardiovascular conditions. Herein, we aimed to explore the role of SII in the prediction of LVT formation in anterior STEMI patients following primary percutaneous coronary intervention (PCI). Methods: Medical records of 124 anterior STEMI patients who developed LVT following primary PCI and 124 age and sex-matched anterior STEMI patients without formation of LVT following primary PCI were analyzed. For each group, patient demographics, comorbidities, laboratory parameters, ECG and echocardiographic findings were analyzed. The SII was measured using the following formula: SII= total peripheral platelets count x neutrophil/lymphocyte ratio. Results: According to our study, reduced left ventricular ejection fraction and increased SII were identified as independent predictors of LVT formation following anterior STEMI. To determine the SII index cut-off value for predicting LVT formation, the ROC curve was drawn and the best cut-off value was determined as 676.27 (AUC:0.778, 95% CI:0.699-0.858, p&lt;0.001). Above this cut-off value, LVT formation could be predicted with a sensitivity of 66.1% and a specificity of 74.2%. Conclusion: SII is may be used as an independent predictor of LVT formation for anterior STEMI patients following primary PCI.

Rationale and design of the direct oral anticoagulants for prevention of left ventricular thrombus after anterior acute myocardial infarction (APERITIF) trial

Anterior acute myocardial infarction (AMI) is associated with an increased risk of left ventricular (LV) thrombus formation. We hypothesized that adding low-dose oral rivaroxaban to the usual antiplatelet regimen would reduce the risk of LV thrombus in patients with large AMI. APERITIF is an investigator-initiated, multicenter randomized open-label, blinded end-point (PROBE) trial, nested in the ongoing "FRENCHIE" registry, a French multicenter prospective observational study, in which all consecutive patients admitted within 48 hours of symptom onset in a cardiac Intensive Care Unit (ICU) for AMI are included (NCT04050956). Among them, patients with anterior ST-elevation-myocardial infarction (STEMI) or very high-risk non- ST-elevation-myocardial infarction (NSTEMI) patients with involvement of the left anterior descending artery are randomized into 2 groups: Dual Antiplatelet Therapy (DAPT) alone or DAPT plus rivaroxaban 2.5mg twice daily for 4 weeks, started as soon as possible after completion of the initial percutaneous coronary intervention/angiography procedure. The primary endpoint is the presence of LV thrombus at 1 month, as detected by contrast enhanced CMR (CE-CMR). Secondary endpoints include LV thrombus dimension (greatest diameter), the rate of major bleedings and major cardiovascular events at 1 month. Based on estimated event rates, a sample size of 560 patients is needed to show superiority of DAPT plus rivaroxaban therapy versus DAPT alone, with 80% power. The APERITIF trial will determine whether, in patients with large AMIs, the use of rivaroxaban 2.5mg twice daily in addition to DAPT reduces LV thrombus formation, compared with DAPT alone. gov Identifier: NCT05077683.

Spectrum of intracardiac thrombi in different clinical scenarios at a tertiary care center

Cardiologists frequently encounter intracardiac thrombi in the course of their work. Along with tumor and vegetation, it is one of the most frequent differential diagnoses for intracardiac masses. Cardioembolic stroke patients frequently have intracardiac thrombi in the left ventricle. Although the potential for cerebral emboli persists in a large population of patients with chronic left ventricular (LV) dysfunction, the risk of LV thrombus formation is highest during the first 3 months after acute myocardial infarction. The main risk factors for the development of left atrial thrombi are rheumatic valvular disease, especially mitral stenosis and atrial fibrillation. Right heart chamber thrombi may develop in situ or occur when peripheral venous clots that are on their way to the lungs become stuck, leading to acute pulmonary embolism, and their incidence ranges from 4% to 18%. We are presenting five cases that represent a broad range of clinical circumstances involving intracardiac thrombus. When performed during systole and diastole, echocardiography can detect thrombus as a discrete, echo-dense mass with clearly defined borders that is separate from the endocardium. Since dimensions, shape, regularity or irregularity, and homogeneity are all characteristic features that define the embolic risk and therapeutic management, the morphology and structure of thrombi should be carefully assessed.

An Unusual Presentation ofSCAD ina Young Male Soldier.

Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of myocardial infarction and sudden cardiac death in young individuals without significant cardiovascular risk factors. The etiology of SCAD appears to be multifactorial and is often precipitated by physical and emotional stress superimposed on underlying arteriopathy, connective tissue disorders, systemic inflammatory disorders, genetic factors, and hormonal influences. There are no current societal guidelines to stratify young soldiers' risk of developing SCAD. Diagnosis typically requires invasive coronary artery angiography which is largely unavailable in stations with limited medical resources. Furthermore, young patients with SCAD often present with atypical cardiac symptoms, such as heartburn leading to the misdiagnosis of gastroesophageal reflux disease and a delay in diagnosis and management. We present a 21-year-old active duty male who was transferred from Okinawa, Japan to a tertiary military medical center for evaluation of hypercoagulable conditions after CT revealed non-obstructing portal venous thrombosis extending to right hepatic vein, splenic vein thrombosis with splenic infarct, and bilateral wedge-shaped renal infarct. Extensive work-up ultimately revealed mid-left anterior descending spiral dissection with transmural infarct of inferior, anteroseptal, and inferoseptal wall resulting in the formation of left ventricular thrombus, subsequently causing thromboembolism to multiple organs. This case demonstrates the ramifications of SCAD when diagnosis and management are delayed and serve as a poignant reminder for all providers to include SCAD in the differential diagnosis for young soldiers with atypical chest pain.

Anaesthetic management in patient with left ventricular clot posted for non-cardiac surgery

Cardiovascular disease remains the leading cause of mortality all over the world. Mortality from acute myocardial infarction (AMI) has decreased since the introduction of primary percutaneous coronary intervention (PCI). Left ventricular (LV) thrombus is a common complication after acute myocardial infarction (MI). One of the most feared complications is the occurrence of thromboembolic events (mostly cerebrovascular accidents) due to left ventricular (LV) thrombus formation. We present a 65 yrs old male with right traumatic foot ulcer, scheduled for right foot SSG. His ECG showed anterior wall ischemic changes. Echocardiogram showed akinetic LV apex, EF: 47%, with an organised LV apical clot of 1.5×1.4cm. Cardiologist opinion was obtained and he was put on oral nitrates, beta blocker and statins. Surgery was done under right popliteal sciatic nerve and fascisa iliaca block. Intraoperative period was uneventful. Postoperatively, serial ECG and Trop I was done on 1 and 4 POD and was found to be normal. He was discharged on 4 POD, with advice to follow up with cardiologist.

Frequency of LV Thrombus Formation after Anterior Wall St-Segment Acute Myocardial Infarction

Objective: To assess the frequency of thrombus formation in LV post Anterior wall ST Segment elevation acute MI. Methodology: In this descriptive case series during the year 2018 we included 100 cases of age 40-70years of either gender presenting with STEMI planned to undergo Transthoracic echocardiography. Demographic information including name, age, gender, BMI, smoking and diabetes (BSR&gt;186mg/dl) was also noted. Then patients were admitted in cardiology wards and were followed-up there. Then patients were discharged after 3days and were followed-up in OPD for one week. After one week, patients were evaluated on 2-D Transthoracic echocardiography and LV thrombus was labeled. The patients who had LV thrombus, were managed as per hospital protocol. Results: The mean age of patients was 56.68±8.59years. There were 90 (90%) males and 10 (10%) females. The mean BMI of patients was 24.54±3.49kg/m2. There were 43 (43%) smokers and 57 (57%) were non-smokers. There were 36 (36%) diabetics and 64 (64%) were non-diabetics. In this study, 63 (63%) underwent thrombolysis and 87 (87%) underwent primary PCI after STEMI. There were 7 (7%) cases who developed LV thrombus while 93 (93%) were remained free of LV thrombus. Concussion: Frequency of Left ventricular thrombus formation is low in our local population. Keywords: Left ventricular thrombus, anterior wall myocardial infarction, ST-segment elevation myocardial infarction, Transthoracic echocardiography

Predictors of left ventricular thrombus after acute myocardial infarction: a systematic review and meta-analysis.

Left ventricular thrombus (LVT) is a recognized complication of acute myocardial infarction (AMI) which can cause significant morbidity and mortality from systemic embolism. We conducted a systematic review and meta-analysis of factors that have been shown in studies to be independently predictive of LVT post-AMI. A total of 23 studies met the inclusion criteria with 1 047 785 patients. The proportion of patients with LVT ranged from 0.2% in the nationwide study in the USA to 36.1% in the cohort of patients with LV aneurysm. Pooled results from nine studies suggest that greater values for left ventricular ejection fraction is associated with reduced odds of LVT formation [odds ratio (OR) 0.90; 95% confidence interval (CI), 0.86-0.93; I2 = 76%]. Left ventricular aneurysm was a significant predictor of LVT formation (OR 6.07; 95% CI, 2.27-16.19; I2 = 91%; seven studies) and anterior location of MI was also a significant predictor (OR 7.72; 95% CI, 2.41-24.74; I2 = 69%; four studies). Three studies suggest that there was an increase in odds of LVT formation with greater values of C-reactive protein (OR 2.06; 95% CI, 1.07-3.97; I2 = 89%; three studies). The use of glycoprotein IIb/IIIa inhibitors (OR 2.52; 95% CI, 1.55-4.10; I2 = 0%; two studies) and greater SYNTAX score (OR 1.21; 95% CI, 1.08-1.36; I2 = 46%; two studies) were associated with LVT. In conclusion, patients with reduced ejection fraction, AMI and with left ventricular aneurysm are at risk of LVT formation and careful imaging evaluation should be performed to identify LVT in these patients to prevent stroke or peripheral embolism.